Noke' Childcare Registration Form
Full name of child
*
First Name
Middle Name
Last Name
Sex
*
M
F
Date of birth
*
-
Month
-
Day
Year
Date
Family Doctor & Phone Number
*
Please type "none" if the child is without a family doctor.
Personal Health Number (PHN)/ Care Card Number
*
Please type "none" if the child is without a PHN
Start Date at Noke Childcare
*
-
Month
-
Day
Year
Date
Expected End Date
*
-
Month
-
Day
Year
Date
Please provide any considerations regarding allergies, disabilities, illnesses, medications, food/ drinks, or any special instruction respecting participation in a program of activities or other matters relevant to the child's care.
*
Please type "none" if this section is not applicable
Immunizations Y/N (describe if desired or type unsure)
*
Second Child Section
Full name of second child
First Name
Middle Name
Last Name
Sex
M
F
Date of birth
-
Month
-
Day
Year
Date
PHN/ Care Card Number
please type "none" if the child is without a personal health number
Start Date
-
Month
-
Day
Year
Date
Expected End Date
-
Month
-
Day
Year
Date
Allergies/ Illnesses/ Disabilities & Food or Drink Considerations
Immunizations Y/N (describe if desired)
Consent
I will notify you when your child is ill or needs medical attention. In the event that we cannot contact you and we need to get immediate help for your child I require consent to do so. Do you give consent for your child to be taken to the nearest emergency medical centre when you cannot be contacted? Do you give consent for your child to receive medical treatment?
*
Yes
No
Signature of parent
Child's Legal Guardian Information
Primary Legal Guardian
First Name
Last Name
Relationship
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Work Name/Address & Phone
City
State / Province
Postal / Zip Code
Secondary Legal Guardian
If applicable please name the seconday legal guardian
First Name
Last Name
Relationship
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Work Name/ Address & phone
City
State / Province
Postal / Zip Code
Third party access to your child/ren:
Please list any persons not permitted access to the child, if none please state this:
*
Name(s) or N/A
Person authorized to pick up child/ren
First Name
Last Name
Relationship
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary person authorized to pick up child/ren
First Name
Last name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Persons to call in case of emergency if legal guardians can not be contacted:
First Person to be contacted
Second Person contacted
Signature
The Parent Agreement and Payment Policy is agreed to as posted on the website? https://angelaisaac5.wixsite.com/website/general-5
*
Yes
Print
Submit
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